Blood Transfusion Threshold in Patients Receiving Extracorporeal Membrane Oxygenation Support for Cardiac and Respiratory Failure—A Systematic Review and Meta-Analysis

Abbasciano, Riccardo; Yusuff, Hakeem; Vlaar, Alexander P.J.; Lai, Florence; Murphy, Gavin J.

doi:10.1053/j.jvca.2020.08.068

Cited by 19 publications

(15 citation statements)

References 31 publications

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“…A dosedependent relationship between the amount of transfused red blood cells (33) respectively the total of red blood cell units received during ECLS (34) was associated with inhospital mortality and adverse outcomes (35). A recent systematic review suggested that a restrictive transfusion threshold in ECLS management provides favorable outcomes in single-center cohorts (36). Allogeneic blood transfusion and bleeding complications may have some colinearity.…”

Section: Discussionmentioning

confidence: 99%

Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients

Sahli¹,

Kaserer²,

Braun³

et al. 2022

J Thorac Dis

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Background: Extracorporeal life support (ECLS) therapy is increasingly used for cardiac and respiratory support postcardiotomy, refractory cardiogenic shock and cardiopulmonary resuscitation. This study aims to describe in-hospital mortality of patients requiring ECLS, identify independent predictors associated with mortality and analyze changes of mortality over time.Methods: This retrospective study includes all adult ECLS cases at the University Hospital Zurich, a designated ECLS center in Switzerland, in the period 2007 to 2019.Results: ECLS therapy was required in 679 patients (median age 60 years, 27.5% female). In-hospital mortality was 55.5%. Cubic spline interpolation did not detect evidence for a change in mortality over the whole period of 13 years. In-hospital mortality significantly varied between ECLS indications: 70.7% (152/215) for postcardiotomy, 67.9% (108/159) for cardiopulmonary resuscitation, 47.0% (110/234) for refractory cardiogenic shock, and 9.9% (7/71) for lung transplantation and expansive thoracic surgery (P<0.001). Logistic regression modelling showed excellent discrimination in the receiver operating characteristic (ROC) area under the curve (AUC) of 0.89 [95% confidence interval (CI): 0.87-0.92] and identified significant mortality predictors: age, simplified acute physiology score (SAPS) II, as well as new liver failure and each allogenic blood transfusion unit given per day. ECLS after cardiopulmonary resuscitation was associated with significantly higher mortality compared to ECLS for refractory cardiogenic shock. Conclusions:In-hospital mortality of patients treated with ECLS therapy is high. Outcomes have not changed significantly in the observed period. We identified age, SAPS II, new liver failure and each allogenic blood transfusion unit given per day as independent mortality predictors. Knowledge of predictors strongly associated with in-hospital mortality may affect future decisions about ECLS indications and the respective management to use this elaborate therapy more effectively.

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Section: Discussionmentioning

confidence: 99%

Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients

Sahli¹,

Kaserer²,

Braun³

et al. 2022

J Thorac Dis

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“…14 A recent cohort study including 208 patients showed that a liberal transfusion threshold of 9 g/dl did not translate to improvement in patient survival. 6 While a randomized controlled trial of different transfusion thresholds in ECMO patients would be ideal, 8 the low annual number of ECMO episodes in most localities and the fact that cases are spread across different ECMO centers make conducting large randomized controlled trials in ECMO patients difficult, if not impossible. Using territory-wide registry data, our study reflected real-life clinical practice across multiple ECMO centers over the past 10 years and thus provided good evidence for the effect of a restrictive transfusion strategy across the broad groups of V-A, V-V, and ECPR ECMO patients.…”

Section: Discussionmentioning

confidence: 99%

“…A number of observational studies have attempted to determine the transfusion threshold during ECMO, using restrictive transfusion thresholds ranging from 8 to 9 g/dl 6,7 . However, the number of subjects in these studies is limited, and the meta‐analysis did not provide conclusive evidence as to transfusion management in ECMO 8 . Whether transfusion practices in broad categories of critically ill patients could be generalized to patients on ECMO, and if restrictive transfusion strategies may be associated with worse outcomes in this vulnerable population remain to be determined.…”

Section: Introductionmentioning

confidence: 99%

Restrictive and liberal transfusion strategies in extracorporeal membrane oxygenation: A retrospective observational study

Chan

et al. 2022

Transfusion

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Background To compare the outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) support who had a restrictive transfusion strategy with those who had a liberal strategy. Study Design and Methods We retrospectively reviewed all adult patients from 2010 to 2019 who received a minimum of one packed red blood cell (pRBC) during ECMO. Hemoglobin values before each transfusion were retrieved. Restrictive transfusion strategy was defined as a transfusion threshold ≤8.5 g/dl in all transfusion episodes for a single patient, while liberal transfusion strategy was defined as a transfusion threshold >8.5 g/dl in any transfusion episode. Results The analysis included 763 patients, with 138 (18.1%) patients in the restrictive and 625 (81.9%) in the liberal transfusion strategy group. The median hemoglobin level, taking into account all measured hemoglobin values, during ECMO support was 8.3 and 9.9 g/dl, and the average units of pRBC received per day were 0.7 (0.3–1.8) and 1.2 (0.6–2.3), respectively. There were no significant differences in intensive care unit (ICU) mortality (adjusted odds ratio (OR), 0.86; 95% CI 0.56–1.30; p = .47), hospital mortality (adjusted OR, 0.79; 95% CI 0.52–1.21; p = .28), and 90‐day mortality (adjusted OR, 0.84; 95% CI 0.55–1.28; p = .42) between the two groups. Among subgroup analyses, a restrictive transfusion strategy was associated with decreased risk of ICU mortality in patients on veno‐venous ECMO (adjusted OR, 0.36; 95% CI 0.17–0.73; p = .005). There was no heterogeneity on outcomes across patients stratified by age, APACHE IV score, or need for large volume transfusion. Discussion Our data suggested it may be safe to adopt a restrictive red cell transfusion threshold of 8.5 g/dl in patients on ECMO, and highlighted the need for prospective trials in this heavily‐transfused population.

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“…To further simplify the final model for easier implementation in clinical settings, continuous variables in the final model were dichotomized at "8" (LACT-8 model) and a 0−4 summative score for the number of conditions present was created. We selected a cut-off of 8 for several reasons: hemoglobin < 8 g/dl has been found to be a valuable transfusion threshold for patients on ECLS 22 ; while a lactate level of 8 mmol/L is not only universally elevated, it is associated with poor outcomes in patients on VA-ECLS. 23,24 We then assessed the predictive ability of our LACTATE and LACT-8 models versus SOFA and SAVE scores on the basis of oAUC, goodness-of-fit (le Cessie−van Houwelingen normal test statistic and Akaike Information Criteria), specificity, sensitivity, PPV, and negative predictive value (NPV).…”

Section: Statistical Analysis Methodsmentioning

confidence: 99%

Predicting mortality in nonsurgical patients before cannulation for veno‐arterial extracorporeal life support: Development and validation of the LACT‐8 score

Hillerson

Whiteside

Dugan

et al. 2022

Cathet Cardio Intervent

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Objectives: We sought to derive and validate a model to predict inpatient mortality after veno-arterial extracorporeal life support (VA-ECLS) based on readily available, precannulation clinical data.Background: Refractory cardiogenic shock supported by VA-ECLS is associated with high morbidity and mortality.Methods: VA-ECLS cases at our institution from January 2014 through July 2019 were retrospectively reviewed. Exclusion criteria were cannulation: (1) at another institution; (2) for primary surgical indication; or (3) for extracorporeal cardiopulmonary resuscitation. Multivariable logistic regression compared those with and without inpatient mortality. Multiple imputation was performed and optimismadjusted area under the curve (oAUC) values were computed.Results: VA-ECLS cases from August 2019 through November 2020 were identified as a validation cohort. In the derivation cohort (n = 135), the final model included Lactate (mmol/L), hemoglobin (g/dl; Anemia), Coma (Glasgow Coma Scale [GCS] < 8) and resusciTATEd cardiac arrest (LACTATE score; oAUC = 0.760). In the validation cohort (n = 30, LACTATE showed similar predictability [AUC = 0.710]). A simplified (LACT-8) score was derived by dichotomizing lactate (>8) and hemoglobin (<8) and summing together the number of components for each patient. LACT-8 performed similarly (derivation, oAUC = 0.724; validation, AUC = 0.725). In the derivation cohort, both scores outperformed SAVE (oAUC = 0.568) and SOFA (oAUC = 0.699) scores. A LACT-8 ≥ 3 had a specificity for mortality of 97.9% and 92.9%, in the derivation and validation cohorts, respectively. Conclusions:The LACT-8 score can predict inpatient mortality prior to before cannulation for VA-ECLS. LACT-8 can be implemented utilizing clinical data without the need for an online calculator.

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Blood Transfusion Threshold in Patients Receiving Extracorporeal Membrane Oxygenation Support for Cardiac and Respiratory Failure—A Systematic Review and Meta-Analysis

Cited by 19 publications

References 31 publications

Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients

Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients

Restrictive and liberal transfusion strategies in extracorporeal membrane oxygenation: A retrospective observational study

Predicting mortality in nonsurgical patients before cannulation for veno‐arterial extracorporeal life support: Development and validation of the LACT‐8 score

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